CF 100: Chiropractic Maintenance Care, Corticosteroid Shots, 11 Best Practice Recommendations

WOW!! our 100th episode. That feels great to say. We made it to 100! That’s a milestone. And we should celebrate!! Yay!!! What should we do about this? I don’t know. I feel like we should do what got me started which is cover some great research that advocates and validates what we do every single day of our working lives. 

I say today we talk about if alternative non-pharma treatment, chiropractic maintenance care, let’s discuss if steroid injections have been doing more harm than good, & what are the 11 recommendations for high-quality clinical practice guides?

But first, here’s that sweet sweet bumper music

Chiropractic evidence-based products
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OK, we are back and you have found the Chiropractic Forward Podcast where we are making evidence-based chiropractic fun, profitable, and accessible while we make you and your patients better all the way around.  It’s like we’re talking about research over beers.

Welcome, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.  If you haven’t yet I have a few things you should do, like our facebook page, join our private facebook group and interact, and then go review our podcast on iTunes. We have a youtube channel and twitter too but those are the main things. 

You have skidded into Episode #100 and I’m smiling a big, huge toothy grin because of that 100 episode mile marker. Good stuff! Yes, I’m proud of reaching it. Think about it for a second if you will. 

This all started because I found interest in taking research papers and distilling them down into easily understandable soundbites. Why They Did It, How They Did It, What They Found, Wrap It Up. That’s been my blogging format since 2007 and here we are at almost 2020. 

That’s a long time to do something wouldn’t you agree? 13 years. Imagine the amount of blogs and material I have accumulated. Here’s the thing, I’ve never missed a week. 

That’s 13 years times 52 weeks. What is that….let me see here….bippity boppity boop…. and the grand total is 676 blog articles or podcasts. And, if you’ve followed along very long, I usually cover 3-4 research papers PER EPISODE. That comes to an estimated 2000+ papers covered. 

If someone asks you where the research is that backs up chiropractic, I want you to punch them square in the nose in a most violent way. Then, I want you to be able to point them to a resource to shut them up and answer all of their questions. 

Hell, maybe they even turn into an advocate themselves when they see they shear amount of information available if they’re just not lazy and actually seek it out. It’s easier to sit around and bitch. Trust me, I sit around and bitch sometimes too. 

In that spirit, I have created a book wherein I have compiled all of the blogs and all of the information into specific sections. You want research on the neck? Just flip to that section of the book. Right now, it’s sitting about 378 pages but I have some ideas on how to shorten it up some. 

Now if you missed last week’s episode on Marketing an evidence-based practice…. make sure you don’t miss that info. I think there were some good solid knowledge nuggets found there within so make sure you’re up to date and not falling behind the rest. 

On the personal end of things, as with daily practice, problems pop up don’t they? It’s a big long game of whack-a-mole. If you’ve never played the game at the arcade, there are several holes which moles pop up out of the ground randomly and you have to whack them with a mallet to score and keep on moving along in the game. 

Well, in a nutshell, that’s they way small business ownership is wouldn’t you agree? Your office manager has a kid and is gone for a month or more, whack that mole. Your newest staff member just got all good and trained but has decided the job is too hard and wants something with less stress so now you get to hire and train a new girl. Whack that mole. You start to get over the newest new hire and it rains and now you have ceiling tiles that have fallen out of your roof. Blah blah blah

This week, my billing company has decided to close its doors leaving 22 clients to figure out something else in regard to their billing service. We are friends with the owner and it’s not a bad thing. Poor lady has some illnesses in her family and she’s leaving to take care of her family. Who could ever blame her?

Still, we are left to figure it out so I’ve done 10 interviews in the last 2 days and we’re still interviewing. I’ll keep you up-to-date as this new mole has shown it’s head and must be whacked before the next mole pops up out of it’s hole. 

The entrepreneur in me has some ideas if I’m being honest. If you can identify a vaccuum, and you can fill it, well then….you got something you can make some money with. 

Before we dive into the reason we’re here, it’s good to support the people that support you don’t you think? Well, ChiroUp certainly supports evidence-based practices. 

If you don’t take advantage of this deal, I just think you might be crazy.

If you’re a regular listener of our podcast, you know I’ve used ChiroUp since about June of 2018. Let me tell you about it because I’m about to give you a way to do a FREE TRIAL and, if you sign up, only pay $99/month for the first six months which is pennies compared to what it’s worth. So listen up!

ChiroUp is changing the way we practice by simplifying patient education and here’s what I mean: 

In a matter of seconds, you can send condition-specific reports to your patients with recommendations for treatment, for their activities of daily living, & for their exercises. 

You can see how this saves you time – no more explaining & re-explaining your patient’s care, because they have access to it at their fingertips. 

You can be confident that your patients are getting the best possible care, because the reports are populated based on what the literature recommends and isn’t that re-assuring? All of that work has been done FOR you. 

There are more than 1000 providers worldwide using ChiroUp to empower their treatments, patients, & practice – Including myself! **Short testimony**

If you don’t know what it’s all about or you’d like to check it out, do yourself a favor and go to Chiroup.com today to get started with your FREE TRIAL – Use code Williams99 to pay only $99/month for your first 6 months

That’s ChiroUp.com and super double secret code Williams99.

Item #1

The first paper up today is called “Nonpharmacological Treatment of Army Service Members with Chronic Pain Is Associated with Fewer Adverse Outcomes After Transition to the Veterans Health Administration” by Esther Meerwijk, Mary Jo Larson, and Eric Schmidt, et. al.. It was published in the Journal of General Internal Medicine in October of 2019(Meerwijk E 2019). 

Steaming fresh…straight outta the oven. Slap some butter on it.

Why They Did It

Using US Army soldiers, in a population of them having chronic pain, they wanted to compare those that had nonpharma treatment with those that did not. In addition, they wanted to identify any adverse events associated with the non-pharma treatment. 

How They Did It

  • It was a lingitudinal cohort study of active duty Army service members
  • All participants had records of chronic pain
  • Treatments included acupuncture, dry needling, biofeedback, chiropractic care, massage, exercise therapy, cold laser therapy, osteopathic spinal manipulation, transcutaneious electrical nerve stimulation, and other things like US, heat, etc..

What They Found

Non-pharma treatment provided may reduce risk of long-term adverse outcomes. 

Well that’s not news to us but it’s good to have it in black and white on paper. The more of this work that’s done is the more validation. Validation for the things we’ve known all along. We see it every day. Those with questions about chiropractic, they don’t see it every day. It’s not their job to find the info. It’s our job to get it in their hands, bop ‘em on the back of the head, and say….LOOK! 

Item #2

Preventative care, wellness care, chiropractic maintenance care ….I’ve hears so many evidence-based chiropractors through monkey poo at the idea so it’s with great happiness I welcome another paper by Andreas Eklund on the matter. This is actually his second paper on the topic. I will cite the first as well in the show notes which can be found at chiropracticforward.com Episode 100!!

The first paper he did on preventative care vs. symptom related care was published last year, 2018 and was called The Nordic Maintenance Care program: Effectiveness of chiropractic maintenance care versus symptom-guided treatment for recurrent and persistent low back pain—A pragmatic randomized controlled trial.” (Eklund A 2018)

Eklund’s second paper is called “The Nordic Maintenance Care Program: Does psychological profile modify the treatment effect of a preventive manual therapy intervention? A secondary analysis of a pragmatic randomized controlled trial” and was published on October 10, 2019(Eklund A 2019). This was a great step forward in validating chiropractic maintenance care.

Piping hot brew….don’t burn your lips…sip….don’t gulp

Why They Did It

The objective was to investigate whether patients in specific psychological sub-groups had different responses to Chiropractic maintenance care with regard to the total number of days with bothersome pain and the number of treatments.

How They Did It

  • They took data from a two-arm randomized pragmatic multicenter trial 
  • There was a 12-month follow up
  • The follow up was designed to investigate the effectiveness of maintenance care
  • Test subjects had recurrent and persistent low back pain
  • Patients were randomized to either maintenance care or to symptom-related care
  • The primary outcome checked was the total number of days with bothersome low back pain. It was collected weekly for 12 months. 
  • Total number of subjects was 252

What They Found

  • Patients in the dysfunctional subgroup that received MC had fewer days in pain and an equal number of treatments compared to the symptom-related group
  • In the adaptive coper subgroup, patients receiving MC had more days with pain and more treatments. 
  • Patients in the interpersonally distressed subgroup had equal number of days with pain and more treatments with MC

Wrap It Up

Psychological and behavioral characteristics modify the effect of MC and should be considered when recommending long-term preventive management of patients with recurrent and persistent LBP.

So what does that mean to us? Well, if we dive into the paper and read the conclusion, we can get a bit more clarity. 

They say, if we’re going to be recommending chiropractic maintenance care, we need to be making that recommendation to the right kind of patient. Evidentally, chiropractic maintenance care isn’t effective for everyone. 

They say, quote, “Patients who show a favorable response to an initial course of chiropractic care should be considered for chiropractic maintenance care if they report high pain severity, marked interference with everyday life due to pain, high affective distress, low perception of life control and low activity levels at baseline.” 

I beg for patients like this. Because I like to be the hero and I know I can help people like this. High pain….that just means there’s nowhere to go but to feel better. 

Interference with daily life, high distress, low perception of life control, low levels of activity…..Those things ALL spell H E R O in my office because we chiropractors can absolute nail this type of case. 

They say that, on the other hand, if a patient reports low pain severity, low interference with everyday life due to pain, low life distress, high activity levels and a high perception of life control, they probably should not be recommended chiropractic maintenance care and should only get symptom-related care…..as needed basically. 

Pretty interesting stuff on chiropractic maintenance care!

Item #3

I got this from an article in Medical Express and published by Radiological Society of North America. This is one of those articles and one of those papers that is probably making medical doctors’ butts pucker up around the world as we speak(Guermazi A 2019). 

Well, these shots, as I have suspected for some time, they may not be so muy bueno. 

We know the medical kingdom makes a gob of money from corticosteroid shots. We know they’ve never met one they didn’t immediately love. And we know they have paid off boats and houses off these shots. 

The article is called “New evidence that steroid injections of hip and knee may damage joint.”  It was published on Medical Express on the 15th of October 2019. Steaming plate, don’t touch the plate…it fresh from the oven people. 

In the article, they start by saying that the injections have been used to treat osteoarthritis pain in the hips and knees and, as we are all aware of personally, every other joint in the body from fingers to shoulders as well. 

The injections have traditionally been used to treat the pain and swelling in joints in the hopes of getting them to calm down. 

A recent study by Ali Guermazi, MD, PhD, et. al. of Boston University School of Medicine found that these injections may be associated with complications that potentially accelerate the destruction of the joint and may hasten the need for total hip and knee replacements. 

So, what was once suspected to only be good and not bad can be bad. 

To be more specific, they identified four main adverse effects. 

  1. accelerated osteoarthritis progression with loss of joint space
  2. subchondral insufficiency fractures which are stress fractures happening beneath the cartilage
  3. complications from osteonecrosis, and 
  4. rapid joint destruction including bone loss. 

The go on to say that this information should be a part of the consent when injection is indicated. 

Item #4

This last one is called “What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review” and was authored by Ivan Lin, Louise Wiles, Rob Waller, et. al. and published in the British Medical Journal in March of 2019(Lin I 2019). 

It’s not piping hot but there still some steam coming off of the plate. It’s damn sure not room temp just yet. 

Why Th Did It

They wanted to identify common recommnedations for high-quality care for the most common musculoskeletal pain siates that clinicians encounter in embergency and in priimary care seetting. For conditions ranging from spinal condiditons to hip, knee and shoulder. 

How They Did It

It was a systematic review 

It focused on adults 

Four databases were used which were Medline, Embase, CINAHL, and PHysiotherapy Evidence Database. 

6232 recrods identified and they whittled that down to 11 they could rate as being high quality. 

The 11 recommendations for MSK pain care identified were:

  1. Ensure care is Patient-centered
  2. Screen for red flags
  3. Assess physchosocial factors
  4. Use imaging selectively
  5. Undertake a physical examination
  6. Monitor patient progress
  7. Provide education/information
  8. Address physical activity/exercise
  9. Use manual therapy only as an adjunct to other treatments
  10. Offer high-quality non-surgical care prior to surgery
  11. Try to keep patients at work

Wrap It Up

The authors say, “These 11 recommendations guide healthcare consumers, clinicians, researchers, and policy makers to manage MSK pain. This should improve the quality of care of MSK pain.”

Bam!

Research and evidence is moving away from the old. Just go through that list. It means that if your office is doctor-centered, it’s low-quality. 

It means that if you’re doing re-x-rays to prove your treatment, you’re practicing low-quality care. 

If you don’t do a proper physical exam, that included dermatomes, reflexes, and muscle strength, then you are low quality. 

If you aren’t making use of ACCEPTED periodic Outcome assessments, you are low quality. I’m not talking about the myosphere or AK muscle testing here either. 

If you’re not guiding the patient in some sort of exercise/rehab, you are likely a low quality doctor. 

If spinal manipulation, in general, is your only means with which you treat patients, you are most certaily a low quality doc. That doesn’t mean you’re stupid. It doesn’t mean you’re not respected by a lot of people. But it does mean that the high-quality docs use a broad management approach using every tool in their tool boxes that is appropriate and responsible. 

Food for thought. I usually pop off a couple of remarks that will challenge dogma and probably piss some people off. Honestly, that’s not the point. Some of my best friends are more on the TOR, philosophy side of things. I love them. I respect them and I respect their intelligence. We just happen to fundamentally disagree on whether we should engage in healthcare practice from a faith-based stance or from an evidence-based footing. 

I remain steadfast in where I stand on the matter. 

That wraps up episode 100!!

Key Takeaways

Chiropractic maintenance care is now evidence-based. chiropractic maintenance care can be confidently recommended while still remaining evidence-based and patient-centered. That feels good. Thank you Andreas Eklund, et. al.

If you are following the 11 Best Guides, you are evidence-based and right where you need to be.

Corticosteroid shots are not the bees knees. In fact, they can damage your knees. : )

Store

Part of making your life easier is having the right patient education tools in your office. Tools that educate based on solid, researched information. We offer you that. It’s done for you. We are taking pre-orders right now for our brand new, evidence-based office brochures available at chiropracticforward.com. Just click the STORE link at the top right of the home page and you’ll be off and running. Just shoot me an email at dr.williams@chiropracticforward.com if something is out of sorts or isn’t working correctly. 

If you’re like me, you get tired of answering the same old questions. Well, these brochures make great ways of educating while saving yourself time and breath. They’re also great for putting in take-home folders. 

Go check them out at chiropracticforward.com under the store link. While you’re there, sign up for the newsletter won’t you? We won’t spam you. Just one email per week to remind you when the new episode comes out. That’s it. 

Chiropractic evidence-based products
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The Message

I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment instead of chemical treatments like pills and shots.

When compared to the traditional medical model, research and clinical experience show that many patients get good or excellent results through chiropractic for headaches, neck pain, back pain, joint pain, to name just a few.

Chiropractic care is safe and cost-effective. It can decrease instances of surgery & disability. Chiropractors normally do this through conservative, non-surgical means with minimal time requirements or hassle to the patient. 

And, if the patient develops a “preventative” mindset going forward from initial recovery, chiropractors can likely keep it that way while raising the general, overall level of health of the patient!

Key Point:

Patients should have the guarantee of having the best treatment offering the least harm.

That’s Chiropractic!

Contact

Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show or tell us your suggestions for future episodes. Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on iTunes and other podcast services. Y’all know how this works by now so help if you don’t mind taking a few seconds to do so.

Help us get to the top of podcasts in our industry. That’s how we get the message out. 

Connect

We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward. 

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About the Author & Host

Dr. Jeff Williams – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger

Bibliography

  • Eklund A (2018). “The Nordic Maintenance Care program: Effectiveness of chiropractic maintenance care versus symptom-guided treatment for recurrent and persistent low back pain—A pragmatic randomized controlled trial.” PLoS One 13(9).
  • Eklund A, J. I., Leboeuf-Yde C, Kongsted A, Jonsson M, Lovgren P, (2019). “The Nordic Maintenance Care Program: Does psychological profile modify the treatment effect of a preventive manual therapy intervention? A secondary analysis of a pragmatic randomized controlled trial.” PLoS One.
  • Guermazi A (2019). “Intra-articular Corticosteroid Injections of the Hip and Knee: Perhaps Not as Safe as We Thought?” Radiology.
  • Lin I, W. L., Waller R, Goucke R, (2019). “What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review.” Br J Sports Med 0: 1-10.
  • Meerwijk E, L. M., Schmidt E, (2019). “Nonpharmacological Treatment of Army Service Members with Chronic Pain Is Associated with Fewer Adverse Outcomes After Transition to the Veterans Health Administration.” J Ge intern Med.

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